Sarcoidosis: a rare cause of Kleine-Levine-Critchley Syndrome

noticed a dramatic increase in appetite. He became ravenous and gained more than 80 pounds in less than six months. His uncontrollable hyperphagia turned into a family crisis. Soon after he developed diabetes mellitus, dyspnea, and hypersomina. In May 2004, his parents noted symptoms of cognitive changes, including difficulties with short-term memory, fatigue, confusion, irritability, and aggres-sion. In June and July 2004, the patient was involved in two motor vehicle accidents; his parents were con-vinced sleepiness and poor concentration were the main reasons for the mishaps. Physical examination revealed a morbidly obese man with a marked buffalo-hump and a plethoric, Cushingoid face. Neurologically, the mini mental status revealed a 27/30 (missed the date, country and 1 out of 3 on recall). His gait was wide base with normal stride. The toe and heel gait were intact, but slightly unsteady with tandem. A magnetic resonance image of the brain re-vealed extensive leptomeningeal enhancement, espe-cially in the basal cisterns that extended up to the in-terior hemispheric fissure and sylvian fissure (Fig. 1). The chest radiograph showed mediastinal and bilat-eral hilar adenopathy. A subsequent serum ACE lev-el drawn measured at 33 micrograms/L. Mediastinal lymph node biopsy revealed a non-caseating granu-loma, confirming the diagnosis of sarcoidosis. The acid fast stains and GMS stains were negative. No biopsies from the brain lesions were obtained, since adequate evidence was present to attribute the neu-rological derangements to neurosarcoidosis. A sleep polysomnography confirmed the presence of ob-structive sleep apnea. A CPAP machine was provid-ed, which the patient used inconsistently. Hormones measurement included cortisol 12 micrograms/dL, thyroid stimulating hormone 0.122 mIU/L, follicular stimulating hormone 1.8 mIU/ mL, and lutenizing hormone 1.6m IU/ml, and pro-lactin 10.7 ng/mL and hemoglobin A1c 8.9%. The patient was given prednisone 40 mg/day. He had radiographic and clinical improvement on subsequent follow-up visits. Unfortunately, the pa